THE READERS' CORNER

Topics are innovations in orthodontic practice and ethics.

1. What appliance innovation has made the biggest positive impact in your practice in the past five years ?

About 40% of the respondents named ceramic brackets as their most important appliance innovation. Cetlin-style mechanics (mentioned as both an appliance and a technique) received about 20% of the responses, and the Herbst and SPEED appliances 10% each.

What technique innovation?

The introduction of new archwires (principally nickel titanium) was mentioned by about one-third of the clinicians, while nearly an equal number felt that bonding improvements such as light curing, Scotchbond, and prescription indirect bonding were the most beneficial innovations. About 15 % reported that articulator mounting, particularly with the SAM system, had significantly improved their practices in the past five years.

Comments included:

"The light-activated bonding technique has been a big benefit. This has allowed me to instantaneously bond brackets or fixed lingual retainers. Speed and ease of application has allowed me to be more efficient and given me the confidence that the bracket or retainer is totally cured, so that activation can be immediately placed in the appliance."

What administrative innovation?

An overwhelming majority answered "computers". Word processing, financial controls, and scheduling, in that order, were the most commonly reported uses of computer systems. Controlling the schedule, by means of a treatment coordinator and delegation of treatment conferences, was the other innovation mentioned by several orthodontists.

What patient-management innovation?

There was no definitive answer to this question. Two of the many suggestions included:

"Through our use of an in-house computer, we have been able to have more information as to how a patient is progressing. This has allowed us to more effectively schedule progress consultations to personally discuss problem areas with parents. This has allowed us to more effectively place the responsibility where it belongs, upon the shoulders of the patient and parent."

"Getting the parents more involved by personal telephone calls and in-office discussions, particularly regarding headgear cooperation."

What staff-management innovation?

Profit-sharing schemes, especially those involving bonuses based on three-month collection averages, were the most popular response. The use of regular monthly staff meetings with structured agendas was also felt to be an important innovation.

Specific comments included:

"A bonus system in the office based on production has allowed the staff to share in the profits of my office and has been a tool which gives the staff a feeling of togetherness and sharing in the benefits of the practice."

"Each week we spend from one half-hour to one hour teaching each staff member every phase of the orthodontic practice--i.e., mechanics, soldering, wire bending, even diagnosis (although I do all of the diagnoses). We call it 'mini-ortho school' ."

What practice-building innovation?

Staying in close contact with referring practitioners was the method cited most often. This might involve more correspondence, more lunches, or bringing in staff from other offices for lunch. Showing concern for patients, including follow-up telephone calls, was also frequently mentioned.

Some specific responses:

"It is common for the general dentist to feel that he has lost control of his patients once they enter orthodontic care. Many patients simply stop visiting their dentist once the braces are put on. We have instituted a program where letters are sent to all referring dentists each month, listing the patients we feel are due for examinations at that time. This stresses the fact that we are definitely concerned about their patients' welfare as well as helping to maintain a continuity with our referring doctors."

"Limiting my practice to adults only and using prescription cephalometric analysis by computer and video imaging."

"Sending out a patient questionnaire to every patient who visits our office in any given month. Taking that data and evaluating each area of our practice so as to better ourselves."

2. You refer a patient to an oral surgeon for the extraction of four first bicuspids. When the patient returns following the extractions, you observe that three bicuspids and a cuspid have been extracted. What do you tell the patient? What do you tell the surgeon ?

More than 95% of the respondents said they would tell the patient, although many said they would first check with the oral surgeon to find out what had happened. They would usually tell the patient that the situation was manageable, but that it would require a longer treatment time. The potential need for restorative care after orthodontics was often mentioned as a point to discuss with the patient.

Many clinicians said they would give the surgeon the benefit of the doubt, but would base their decision on whether to refer future patients on how the surgeon replied to their questions and accepted responsibility if appropriate. Checking the extraction order before calling the surgeon was mentioned by several as an important first step.

The numerous comments included:

"I tell the patient the truth, replan the case, and suggest that the oral surgeon bear the cost of any prosthetics needed to complete the case."

"This actually happened to one of my patients. I felt I had to point it out, and did so, because it would complicate treatment for me and possibly result in a slightly less than ideal esthetic result. The parents were incensed at the oral surgeon and wanted to initiate legal proceedings. I succeeded in urging forbearance and patience to wait and see what the end results would be. I indicated that I thought we could disguise the mistake well enough that they would find treatment results acceptable. It was not easy to persuade them to go along, but they did. Their tempers cooled, and they were satisfied with the result and brought no suit."

"First, I would check my extraction request and establish if there was poor communication between my office and his. Second, I would inform the oral surgeon of the mistake and ask that he contact the patient after me, and reassure the patient that he had talked with me and that under most situations the problem would still have a satisfactory result. Third, I would call the patient and let the patient and parents know that although a tooth was removed that we prefer to have, generally a good result could still be achieved and treatment goals reached, although there may need to be some contouring of the remaining bicuspid."

On progress x-rays of a patient's upper incisors, you notice incipient root resorption that you think is insignificant. Do you tell the patient? Do you make a note on the patient's chart?

Ninety percent of the practitioners said they would tell the patient immediately, while the other 10% would wait three to six months, take another radiograph, and then inform the patient if the situation had worsened. Virtually every respondent would write a note in the patient's chart at once, and several recommended using red ink. Many clinicians suggested they would reduce the amount of force they were using and try to complete the case as soon as possible, taking progress films at six-month intervals.

You have just referred a lovely child to an oral surgeon and had the first four bicuspids extracted. Now you learn that the parents are about to enter a divorce proceeding and that neither one can accept responsibility for payment of the fee until the divorce is settled. What do you do?

The consensus was that everybody has had a problem such as this, and nobody has a good solution. Recurring suggestions included trying not to start the case at all (with hindsight), as well as putting the patient on "maintenance", perhaps with space maintainers, until the situation was resolved. Many orthodontists felt obliged to continue active treatment and try to rearrange the payment over a longer period with the custodial parent.

Comments included:

"Stock answer: treat the kid anyway. Realistic answer: I'm a little tired of being the only one who seems to care about the patient (in some situations). Best answer: place space maintainers and wait until all systems (including financial) are go. Then attitude (and probably result) will be better."

"This has happened. I had separate conferences with parents and decided to commence treatment. I made a point to send a letter to each parent's attorney outlining our situation. Treatment costs became a part of the settlement."

"I would wait until the divorce is settled to start the case. If preservation of anchorage was a concern, I would probably place space maintainers."

"I insist that the parent with custody assume the payments and the divorce proceedings are not my concern. If there is no risk to the child's successful treatment, I will 'call their bluff' for a month or two to encourage payment. If still not settled, I will treat the child and continue to pressure the parents to pay."

"First, I would go ahead and treat the case and hope for the best. As a Christian, I would not blame the child for the divorce and realize that the child probably has been through a great deal with the break-up of her family life. I would probably treat the child as a charity case and hope that the parents come forward with some responsibility. Second, if I did not want to treat the child until the divorce was settled and a responsibility was named for her care, then I would place space maintainers until the divorce was settled."

"Once extractions are done, I would continue the case, make sure a finance charge or billing charge was made on late or no payment, and later take the matter to the court system for collection as needed. I would also make a copy of the contract and the informed consent and send to involved parents and their lawyers."

JCO wishes to thank the following contributors to this month's column:

Dr. Louis D. Anderson, Katy, TX

Dr. Earl F. Augspurger, Sioux City, IA

Dr. Gerald R. Carlson, Arlington Heights, IL

Dr. R. Joseph Clark, Seymour, IN

Dr. Kenneth R. Diehl, Durham, NC

Dr. John C. Dumars, Napa, CA

Dr. Lee I. Edwards, Pittsford, NY

Dr. Bruce D. Fiske, Hillsboro, OR

Dr. John W. Fischer, Cincinnati, OH

Dr. Devek K. Frech, Wichita Falls, TX

Dr. John P. Gibbs, Burlingame, CA

Dr. Jeff Haskins, Aurora, CO

Dr. Stephen R. Haught, Emporia, KS

Dr. Randall N. Inouye, Lihue, HI

Dr. Earl Johnson, Mill Valley, CA

Dr. William J. Kottemann, Coon Rapids, MN

Dr. John S. Lamsam, Los Angeles, CA

Dr. Stuart T. Messinger, Havertown, PA

Dr. Peter B. Mills, Atlanta, GA

Dr. Donald A. Morgan, Houston, TX

Dr. Jim Bill Morrow, Abilene, TX

Dr. Thomas Murphy, Duluth, MN

Dr. Herbert Napell, Concord, CA

Dr. Robert G. Nowlin, Waco, TX

Dr. Joseph Pomerantz, Teaneck, NJ

Dr. Gary Roebuck, New City, NY

Dr. John Russell, Columbus, MS

Dr. Edward V. Shagam, Mount Holly, NJ

Dr. Hugh R. Silkensen, Russellville, AR

Dr. Vonnie B. Smith, Raleigh, NC

Dr. John R. Snyder, Cerritos, CA

Dr. Richard Starr, Vero Beach, FL

Dr. Terry L. Thames, Carrollton, TX

Dr. Mark E. Thomson, Plattsburgh, NY

Dr. Charles B. Thornton, Lake St. Louis, MO

Dr. Timothy J. Tremont, McKeesport, PA

Dr. Joseph M. Waldron, Gainesville, FL

Dr. David W. Warren, Miami, FL

Dr. Raleigh Williams, Tucson, AZ

Dr. Julie A. Wong, Sacramento, CA

Dr. Robert T. Workinger, Marshfield, WI

Dr. Maha A. Yousif, Torrington, CT

Dr. Jeff S. Zapalac, Austin, TX

Dr. Michael R. Zukor, Atlanta, GA